Acute Viral Gastroenteritis in Children in Resource-rich Countries - Clinical Features and Diagnosis

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Official reprint from UpToDate® www.uptodate.com ©2017 UpToDate®

Acute viral gastroenteritis in children in resource-rich countries: Clinical features and diagnosis Author: David O Matson, MD, PhD Section Editors: Morven S Edwards, MD, George D Ferry, MD Deputy Editor: Mary M Torchia, MD

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: May 2017. | This topic last updated: May 26, 2017. INTRODUCTION — The epidemiology, clinical features, and diagnosis of acute viral gastroenteritis in children in resource-rich countries will be discussed here. The prevention and treatment of acute viral gastroenteritis in children in resource-rich countries, acute diarrhea in children in resource-limited countries, and chronic diarrhea in children are discussed separately. ● (See "Acute viral gastroenteritis in children in resource-rich countries: Management and prevention".) ● (See "Approach to the child with acute diarrhea in resource-limited countries".) ● (See "Overview of the causes of chronic diarrhea in children in resource-rich countries" and "Approach to the diagnosis of chronic diarrhea in children in resource-rich countries" and "Persistent diarrhea in children in resource-limited countries".) DEFINITION — Acute gastroenteritis is a clinical syndrome often defined by increased stool frequency (eg, ≥3 loose or watery stools in 24 hours or a number of loose/watery bowel movements that exceeds the child's usual number of daily bowel movements by two or more), with or without vomiting or [1-4]. It usually lasts less than one week and not longer than two weeks. Diarrhea that lasts >14 days is "persistent" or "chronic." Diarrhea that recurs after seven days without diarrhea is "recurrent." Acute viral gastroenteritis is caused by a viral pathogen. Acute gastroenteritis also may be caused by bacteria and parasites. (See 'Etiology' below.) PATHOGENESIS — The major clinical manifestations of viral gastroenteritis are caused by intestinal infection and destruction of enterocytes, which results in transudation of fluid into the intestinal lumen and net loss of fluid and salt in the stool [5-9]. Intestinal injury also decreases the ability to digest food, particularly complex carbohydrates, and to absorb digested food across the intestinal mucosa. The pathogenesis of acute diarrhea is discussed detail separately. (See "Pathogenesis of acute diarrhea in children" and "Clinical manifestations and diagnosis of rotavirus infection", section on 'Pathogenesis'.) Factors associated with severe or prolonged clinical manifestations include [10-15]: ● First infection with a particular pathogen ● Malnutrition ● Immune compromise ● Lack of maternally acquired immunity (eg, antibody acquired transplacentally or in human milk) ● Community change in serotype of the infecting strain ● Large inoculum size ● Strain with enhanced virulence EPIDEMIOLOGY — Acute viral gastroenteritis occurs throughout the year with a fall and winter predominance (table 1) [16-19]. Acute viral gastroenteritis can be transmitted by asymptomatic carriers as well as by symptomatic patients before the onset of symptoms [4,20,21]. It is generally transmitted by the fecal-oral route. The possibility of airborne transmission of rotavirus and norovirus has been suggested in some outbreaks [22-24]. Illness usually begins 12 hours to 5 days after exposure and generally lasts for three to seven days [5,7,8]. ETIOLOGY — The most common causes of acute viral gastroenteritis in children include (table 1): ● Rotavirus – Rotavirus gastroenteritis usually occurs in children between six months and two years of age [25,26]. It occurs in the fall and winter in temperate climates and throughout the year in tropical climates (table 1). (See "Clinical manifestations and diagnosis of rotavirus infection".) Rotavirus has historically been the most common cause of medically attended viral gastroenteritis in children; however, in countries that routinely immunize infants against rotavirus, rotavirus gastroenteritis has decreased substantially (figure 1) [27,28]. Laboratory surveillance in the United States, covering the period from 2000 to 2014, observed a 58 to 90 percent reduction in rotavirus detections in each of the seven postvaccine years [29]. (See "Rotavirus vaccines for infants", section on 'Efficacy/effectiveness'.) ● Norovirus – Norovirus gastroenteritis occurs in people of all ages. It occurs year-round, with a peak in the fall and winter [30]. Norovirus is highly contagious and the leading cause of outbreaks of gastroenteritis [21,31,32]. Older children and adolescents with severe acute gastroenteritis, especially as part of a common source outbreak (food, water source, or fomite), are more likely to have norovirus than other causes of acute gastroenteritis [21,33-37]. Norovirus also causes sporadic gastroenteritis, which occurs primarily in young children [38]. (See "Norovirus".)

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Norovirus is, or is becoming, the leading cause of medically attended gastroenteritis in children in countries that immunize infants against rotavirus gastroenteritis [27,28,30,39]. In laboratory surveillance from three counties in the United States (in New York, Ohio, and Tennessee) during 2009 and 2010, norovirus was detected in 17 percent of fecal specimens from children (40°C [104°F]), tenesmus, central nervous system symptoms (eg, seizures), severe abdominal pain, and smaller volume stools are more characteristic of bacterial pathogens [1,25,49,58], but seizures have been reported in rotavirus and norovirus gastroenteritis [62,63]. ● Exposures (eg, international travel, exposure to poultry or other farm animals, consumption of processed meat). ● An elevated band count (if complete blood count is performed) is suggestive of bacterial gastroenteritis. Bacterial causes of acute gastroenteritis in children include: ● Some Escherichia coli spp (see "Microbiology, pathogenesis, epidemiology, and prevention of enterohemorrhagic Escherichia coli (EHEC)" and "Clinical manifestations, diagnosis and treatment of enterohemorrhagic Escherichia coli (EHEC) infection" and "Clinical manifestations and diagnosis of Shiga toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome (HUS) in children") ● Salmonella strains (see "Nontyphoidal Salmonella: Microbiology and epidemiology" and "Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever" and "Nontyphoidal Salmonella: Gastrointestinal infection and carriage") ● Shigella species (see "Shigella infection: Clinical manifestations and diagnosis") ● C. difficile (see "Clostridium difficile infection in children: Microbiology, pathogenesis, and epidemiology" and "Clostridium difficile infection in children: Clinical features and diagnosis") ● Campylobacter jejuni (see "Microbiology, pathogenesis, and epidemiology of Campylobacter infection" and "Clinical manifestations, diagnosis, and treatment of Campylobacter infection") ● C. upsaliensis (see "Infection with less common Campylobacter species and related bacteria", section on 'Campylobacter upsaliensis') ● Mycobacteria, such as Mycobacterium avium complex, particularly in immunocompromised patients (see "Disseminated nontuberculous mycobacterial (NTM) infections and NTM bacteremia in children", section on 'Clinical features') Parasitic causes of acute gastroenteritis in children include: ● Giardia (see "Epidemiology, clinical manifestations, and diagnosis of giardiasis")

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● Cryptosporidium (see "Epidemiology, clinical manifestations, and diagnosis of cryptosporidiosis") ● Cystoisospora belli (formerly known as Isospora belli) (see "Epidemiology, clinical manifestations, and diagnosis of Cystoisospora infections") ● Microsporidia and Cyclospora (see "Microsporidiosis" and "Cyclospora infection") Extraintestinal infections — Extraintestinal infections that may present with diarrhea and/or vomiting are listed below [25,50]. These infections can usually be differentiated from acute gastroenteritis by their extraintestinal manifestations and/or specific laboratory tests (eg, chemistry, cell count, and culture of cerebrospinal fluid; urinalysis and urine culture; etc). ● Meningitis – Characteristic features of meningitis include fever, altered level of consciousness, and meningeal signs. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Clinical features' and "Viral meningitis: Clinical features and diagnosis in children".) ● Bacterial sepsis – Clinical features of sepsis include alterations in vital signs and white blood cell count indicating a systemic inflammatory response syndrome (SIRS) in the presence of clinical or laboratory findings of infection. (See "Systemic inflammatory response syndrome (SIRS) and sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis".) ● Pneumonia – Clinical features of pneumonia include fever and symptoms or signs of respiratory distress (eg, tachypnea, nasal flaring, grunting, retractions, crackles, decreased breath sounds). (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Clinical presentation'.) ● Urinary tract infection (UTI) – Clinical features of UTI include suprapubic or flank tenderness, dysuria, urgency, frequency). (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Clinical presentation'.) ● Otitis media – Symptoms and signs of otitis media include ear pain, bulging of the tympanic membrane, and hearing loss. (See "Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications", section on 'Clinical manifestations' and "Acute otitis media in children: Diagnosis", section on 'Clinical diagnosis'.) Noninfectious conditions — A number of noninfectious conditions can present with symptoms the mimic those of infectious gastroenteritis (table 8). The approach to distinguishing these conditions from acute viral gastroenteritis is discussed separately. (See "Approach to diarrhea in children in resource-rich countries" and "Approach to the infant or child with nausea and vomiting".) INDICATIONS FOR REFERRAL — Urgent referral for diagnostic evaluation and therapy may be warranted in children with: ● Diarrhea lasting more than seven days (see "Overview of the causes of chronic diarrhea in children in resource-rich countries" and "Approach to the diagnosis of chronic diarrhea in children in resource-rich countries") ● Severe dehydration (table 2) associated with cardiovascular instability ● Hypernatremia (see "Hypernatremia in children") ● Clinical features suggesting extraintestinal involvement or another etiology (eg, hemolytic uremia syndrome) (see 'Differential diagnosis' above) ● Immune compromise SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute diarrhea in children".) INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) ● Basics topics (see "Patient education: Viral gastroenteritis (The Basics)" and "Patient education: Diarrhea in children (The Basics)" and "Patient education: Rotavirus infection (The Basics)") ● Beyond the Basics topic (see "Patient education: Acute diarrhea in children (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS ● Acute gastroenteritis is a clinical syndrome often defined by increased stool frequency (eg, ≥3 loose or watery stools in 24 hours or a number of loose/watery bowel movements that exceeds the child's usual number of daily bowel movements by two or more) with or without vomiting or fever. Acute viral gastroenteritis is caused by a viral pathogen. (See 'Definition' above.) ● Acute viral gastroenteritis occurs throughout the year with a fall and winter predominance (table 1). It can be transmitted by

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asymptomatic carriers as well as by symptomatic patients before the onset of symptoms. It is generally transmitted by the fecal-oral route. (See 'Epidemiology' above.) ● The most common causes of acute viral gastroenteritis in children include rotavirus, norovirus, sapovirus, astrovirus, and enteric adenoviruses (table 1). Mixed viral infections are common, but the clinical significance of coinfection with multiple viruses is unclear. (See 'Etiology' above.) ● Among symptomatic patients, the clinical manifestations include diarrhea, vomiting, fever, anorexia, headache, abdominal cramps, and myalgia. The constellation of symptoms varies from day to day and from person to person. (See 'Clinical presentation' above.) ● Acute viral gastroenteritis may be complicated by dehydration, electrolyte and acid-base disturbances, carbohydrate intolerance, and irritant diaper dermatitis. Acute viral gastroenteritis that requires medical attention for dehydration occurs predominantly in young children, particularly those younger than two years. (See 'Complications' above.) ● The history (table 3) and examination (table 4) of children with symptoms and signs of gastroenteritis focus upon determining the severity of illness (table 2) and evaluating other causes of diarrhea and/or vomiting that require definitive therapy (eg, meningitis, acute abdominal processes, diabetes mellitus, and toxic ingestions) and can be confused with acute gastroenteritis in the first day or two of symptoms. (See 'History and examination' above.) ● Laboratory evaluation is not usually necessary but may be warranted in children who require intravenous hydration for severe dehydration or have an atypical presentation (table 5) or if conditions other than acute viral gastroenteritis cannot be excluded clinically. (See 'Laboratory evaluation' above.) ● The diagnosis of acute viral gastroenteritis is made by the characteristic history of diarrhea that does not contain gross blood or mucus; with or without vomiting, fever, or abdominal pain; and the absence of findings more characteristic of bacterial or parasitic gastroenteritis, extraintestinal infections, or noninfectious conditions associated with diarrhea and vomiting (table 5). (See 'Diagnosis' above.) ● The differential diagnosis of acute viral gastroenteritis includes bacterial and parasitic gastroenteritis, extraintestinal infections, and noninfectious conditions. These conditions generally are associated with features that are atypical for acute viral gastroenteritis (table 5). (See 'Differential diagnosis' above.) Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Guarino A, Ashkenazi S, Gendrel D, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr 2014; 59:132. 2. National Institute for Health and Care Excellence. Diarrhoea and vomiting in children: Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. https://www.nice.org.uk/guidance/cg84 (Accessed on May 26, 2017). 3. King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003; 52:1. 4. Velázquez FR, Matson DO, Calva JJ, et al. Rotavirus infection in infants as protection against subsequent infections. N Engl J Med 1996; 335:1022. 5. Schreiber DS, Blacklow NR, Trier JS. The mucosal lesion of the proximal small intestine in acute infectious nonbacterial gastroenteritis. N Engl J Med 1973; 288:1318. 6. Agus SG, Dolin R, Wyatt RG, et al. Acute infectious nonbacterial gastroenteritis: intestinal histopathology. Histologic and enzymatic alterations during illness produced by the Norwalk agent in man. Ann Intern Med 1973; 79:18. 7. Shepherd RW, Gall DG, Butler DG, Hamilton JR. Determinants of diarrhea in viral enteritis. The role of ion transport and epithelial changes in the ileum in transmissible gastroenteritis in piglets. Gastroenterology 1979; 76:20. 8. Mebus CA, Wyatt RG, Kapikian AZ. Intestinal lesions induced in gnotobiotic calves by the virus of human infantile gastroenteritis. Vet Pathol 1977; 14:273. 9. Wilhelmi I, Roman E, Sánchez-Fauquier A. Viruses causing gastroenteritis. Clin Microbiol Infect 2003; 9:247. 10. Kaiser P, Borte M, Zimmer KP, Huppertz HI. Complications in hospitalized children with acute gastroenteritis caused by rotavirus: a retrospective analysis. Eur J Pediatr 2012; 171:337. 11. Henke-Gendo C, Harste G, Juergens-Saathoff B, et al. New real-time PCR detects prolonged norovirus excretion in highly immunosuppressed patients and children. J Clin Microbiol 2009; 47:2855. 12. Sugata K, Taniguchi K, Yui A, et al. Analysis of rotavirus antigenemia in hematopoietic stem cell transplant recipients. Transpl Infect Dis 2012; 14:49. 13. Bok K, Green KY. Norovirus gastroenteritis in immunocompromised patients. N Engl J Med 2012; 367:2126. 14. Morales E, García-Esteban R, Guxens M, et al. Effects of prolonged breastfeeding and colostrum fatty acids on allergic

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manifestations and infections in infancy. Clin Exp Allergy 2012; 42:918. 15. Morrow AL, Ruiz-Palacios GM, Jiang X, Newburg DS. Human-milk glycans that inhibit pathogen binding protect breast-feeding infants against infectious diarrhea. J Nutr 2005; 135:1304. 16. Chhabra P, Payne DC, Szilagyi PG, et al. Etiology of viral gastroenteritis in children 7 days may indicate underlying gastrointestinal or metabolic disease, or systemic disease (eg, IBD, celiac disease, immunodeficiency)

Frequency, volume, and character of stools (eg, blood mucus)

Frequent, watery, large volume without blood or mucus favors viral gastroenteritis Small volume, gross blood, or mucus favors bacterial gastroenteritis Blood or mucus also may occur with intussusception, appendicitis, toxic megacolon

Frequency, volume, and character of emesis (eg, blood, bile, projectile)

Prolonged vomiting increases risk of dehydration and concern for underlying systemic or metabolic disorder Bilious or projectile vomiting may indicate intestinal obstruction (eg, intussusception, pyloric stenosis) Hematemesis may suggest esophageal injury or varices (with underlying liver disease)

Weight before illness

Used to assess degree of dehydration and response to fluid repletion

Urine output

Decreased: suggests dehydration Increased: may indicate diabetes ketoacidosis

Associated symptoms: fever, headache, localized abdominal pain, urinary

May suggest alternate etiology (eg, urinary tract infection,

complaints, and others

appendicitis, and others)

Recent intake of food and fluids

Used to assess degree of dehydration and other causes of diarrhea (eg, starvation stools, food poisoning, food allergy/intolerance, overfeeding [particularly with hyperosmolar fluids])

Underlying medical problems

May increase risk of complications

Recent medications (particularly antibiotics) and medications in the home

May be associated with vomiting or diarrhea Clinical manifestations of certain ingestions may mimic findings of acute gastroenteritis (eg, tachypnea and acidosis in salicylate ingestion)

Immunization history (particularly rotavirus)

Rotavirus immunization decreases likelihood of rotavirus gastroenteritis (even after one dose) Incomplete pneumococcal or Haemophilus influenzae type b immunization may increase likelihood of extraintestinal infection with these organisms (eg, otitis media, pneumonia, meningitis)

Contacts with acute diarrhea or vomiting

Supports infectious gastroenteritis, may suggest a common source outbreak Symptoms may suggest etiology (eg, prominence of vomiting suggests norovirus)

Exposures:

Increases risk of bacterial or parasitic gastroenteritis

Known source of enteric infection (eg, contaminated food or water) Unsafe foods (eg, raw/undercooked meats, eggs, shellfish, unpasteurized milk or juice) Swimming in or drinking untreated fresh surface water Farm, petting zoo, reptiles, pets with diarrhea International travel IBD: inflammatory bowel disease. Graphic 103392 Version 1.0

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Important aspects of the examination of a child with acute gastroenteritis Clinical finding

Potential significance

Growth parameters Body weight

Used to determine degree of dehydration and response to fluid repletion

Growth retardation

Chronic underlying condition (eg, gastrointestinal disease, immune deficiency)

Vital signs Fever: ≥38°C (100.4°F) in patient 40°C [104°F])

≥39°C (102.2°F) in patient ≥3 months Rapid, weak, or absent pulse

Dehydration

Decreased blood pressure

Dehydration, shock, sepsis

Hypotension disproportionate to apparent illness

Adrenal crisis

HEENT Sunken anterior fontanelle, sunken eyes

Moderate to severe dehydration

Bulging anterior fontanelle

Increased intracranial pressure

Scleral icterus

HUS, viral hepatitis

Bulging tympanic membrane

Acute otitis media

Tacky, dry, or parched mucous membranes

Dehydration

Neck Neck stiffness, nuchal rigidity, other meningeal signs

Meningitis

Chest Deep respirations

Moderate to severe dehydration, acidosis

Tachypnea, crackles, decreased breath sounds

Pneumonia

Abdomen Severe, localized pain, rebound tenderness, marked abdominal distension

Acute abdomen (eg, appendicitis, bowel obstruction, toxic megacolon)

Hypoactive/absent bowel sounds

Hypokalemia

Flank pain or suprapubic tenderness

UTI

Abdominal mass

"Olive" at lateral edge of rectus abdominus in RUQ: pyloric stenosis "Sausage-shaped" right-sided mass: intussusception

Skin Cool, mottled, poor capillary refill, decreased turgor

Moderate to severe dehydration, sepsis

Nonblanching lesions (petechiae, purpura, bruises)

HUS, trauma (intracranial, intraabdominal)

Jaundice

HUS, viral hepatitis

Neurologic Altered consciousness or focal neurologic abnormalities

Toxic ingestion, diabetic ketoacidosis, CNS mass, or inborn error of metabolism

RR: respiratory rate; CNS: central nervous system; HEENT: head, eyes, ears, nose, throat; UTI: urinary tract infections; HUS: hemolytic uremic syndrome. Graphic 103393 Version 1.0

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Clinical features atypical for acute viral gastroenteritis in children Clinical feature

Potential significance

Historical features Fever: ≥38°C (100.4°F) in infants 40°C [104°F])

≥39°C (102.2°F) in infants and children ≥3 months Gross blood or mucus in stool

Bacterial gastroenteritis, inflammatory bowel disease

Bilious vomiting

Intestinal obstruction

Projectile vomiting

Pyloric stenosis, intestinal obstruction

Persistent diarrhea (>7 days)

Underlying gastrointestinal, metabolic, or CNS disease

Persistent, recurrent, or isolated vomiting

CNS disease, metabolic disease

Increased urine output

Diabetic ketoacidosis

Altered consciousness, seizures, focal neurologic abnormalities

Increased ICP (CNS mass, hydrocephalus, idiopathic intracranial hypertension)

History of trauma

Intracranial or intraabdominal injury (eg, duodenal hematoma)

Weight loss and multisystem involvement

Parasitic gastroenteritis; underlying gastrointestinal or metabolic disorder

Recent antibiotic exposure

Antibiotic-associated diarrhea, including Clostridium difficile colitis

International travel

Bacterial or parasitic gastroenteritis, measles

Exposures: unsafe foods (eg, raw/undercooked meats, eggs, shellfish,

Bacterial or parasitic gastroenteritis

unpasteurized milk or juice), farm animals, petting zoo, reptiles, pets with diarrhea, untreated surface water Examination Moderate to severe dehydration in a child >2 years

May indicate underlying condition predisposing to dehydration

Bulging fontanelle

Hydrocephalus, meningitis

Bulging tympanic membrane

Acute otitis media

Hypotension disproportionate to apparent illness and/or hyponatremia with hyperkalemia

Adrenal crisis

Tachypnea, retractions, crackles, decreased breath sounds

Pneumonia or other respiratory tract infection

Marked abdominal distention, peritoneal signs, absent bowel sounds or increased high-pitched bowel sounds ("borborygmi")

Acute abdomen (eg, appendicitis, intestinal obstruction)

Focal abdominal tenderness

RLQ: appendicitis, Crohn disease RUQ: gallbladder disease, pancreatitis Suprapubic or flank: UTI Epigastric: pancreatitis, peptic ulcer disease/gastritis

Abdominal mass

"Olive" at lateral edge of rectus abdominus in RUQ: pyloric stenosis "Sausage-shaped" right-sided mass: intussusception

Petechiae, purpura, bruising

Hemolytic uremic syndrome, trauma, extraintestinal infection (eg, RMSF, meningococcemia)

Jaundice

Viral hepatitis, HUS

Signs of trauma

Intracranial or intraabdominal injury (eg, duodenal hematoma)

Increased muscle tone, hyperreflexia

Hyperkalemia

Laboratory findings (if performed) Abnormal CBC

Anemia, thrombocytopenia, hemolysis: HUS Elevated band count: bacterial gastroenteritis Elevated eosinophil count: parasitic gastroenteritis

Elevated serum C-reactive protein, procalcitonin

Bacterial gastroenteritis, inflammatory bowel disease

Fecal leukocytes, fecal lactoferrin, fecal calprotectin

Bacterial gastroenteritis, inflammatory bowel disease

Eosinophils on fecal smear

Amoeba or other intestinal parasite

Persistent watery diarrhea

Microsporidia, Cyclospora, and other intestinal parasites

UTI: urinary tract infection; CNS: central nervous system; ICP: intracranial pressure; RLQ: right lower quadrant; RUQ: right upper quadrant; RMSF: Rocky Mountain spotted fever; HUS: hemolytic uremic syndrome; CBC: complete blood count. Graphic 103390 Version 1.0

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Differential diagnosis of foodborne disease by item consumed Item

Commonly associated microbes*

Raw seafood

Norwalk-like virus, Vibrio spp, hepatitis A

Raw eggs

Salmonella spp

Undercooked meat or poultry

Salmonella spp, Campylobacter spp, STEC, Clostridium perfringens

Unpasteurized milk or juice

Salmonella spp, Campylobacter spp, STEC, Yersinia enterocolitica

Unpasteurized soft cheeses

Salmonella spp, Campylobacter spp, STEC, Y. enterocolitica, Listeria monocytogenes

Homemade canned goods

Clostridium botulinum

Raw hot dogs, deli meat

L. monocytogenes

STEC: shiga toxin-producing Escherichia coli. * This association lists the commonly associated organisms and is not fully comprehensive. Graphic 58714 Version 3.0

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Value of fecal leukocyte examination in distinguishing viral gastroenteritis from other causes of acute gastroenteritis Cause

Type

Frequency, percent

Viruses

PMN, if any

0 to 10

Vibrio cholerae, EHEC, ETEC, EPEC, Giardia lamblia

PMN, if any

0 to 10

Shigella, Salmonella (not typhi), Campylobacter jejuni, Clostridium difficile

PMN

90 to 100

Yersinia enterocolitica, Vibrio parahaemolyticus

PMN

Variable

Salmonella typhi

MN

100

Amoebic dysentery

MN

100

Ulcerative colitis

EO

100

PMN: polymorphonuclear leukocytes; EHEC: enterohemorrhagic Escherichia coli; ETEC: enterotoxigenic E. coli; EPEC: enteropathogenic E. coli; MN: mononuclear leukocytes; EO: eosinophilic leukocytes. Graphic 73254 Version 3.0

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Etiology of diarrhea in children by age Cause Gastrointestinal infections

Non-gastrointestional infections (parenteral diarrhea)

Infants and young children

Older children and adolescents

Viruses *

Viruses *

Bacteria *

Bacteria *

Parasites

Parasites

Otitis media *

Systemic infections

Urinary tract infections *

Staphylococcal toxic shock syndrome ¶

Other systemic infections Dietary disturbances

Functional diarrhea/Overfeeding*

Starvation stools *

Food allergy * Starvation stools * Anatomic abnormalities

Intussusception ¶

Appendicitis ¶

Hirschsprung disease (± toxic megacolon ¶ )

Partial obstruction ¶

Partial bowel obstruction ¶

Blind loop syndrome

Blind loop syndrome (also in patients with dysmotility) Intestinal lymphangiectasis Short gut syndrome Inflammatory bowel disease

Malabsorption or increased secretion

Early onset inflammatory bowel disease (rare, monogenic)

Ulcerative colitis (± toxic megacolon ¶ )

Cystic fibrosis

Celiac disease

Celiac disease Disaccharidase deficiency (eg, lactase deficiency

Disaccharidase deficiency (primary or secondary)*

due to infectious diarrhea)*

Acrodermatitis enteropathica

Acrodermatitis enteropathica

Neuroendocrine secretory tumors

Crohn's disease (± toxic megacolon ¶ )

Congenital secretory diarrhea Immunodeficiency

Severe combined immunodeficiencies and other

HIV

genetic disorders HIV Endocrinopathy

Congenital adrenal hyperplasia

Hyperthyroidism Hypoparathyroidism

Miscellaneous

Antibiotic-associated diarrhea* Pseudomembranous colitis ¶ Toxins Δ Hemolytic uremic syndrome ¶ Neonatal drug withdrawal

Antibiotic-associated diarrhea* Pseudomembranous colitis ¶ Toxins Δ Irritable bowel syndrome * Psychogenic disturbances *

HIV: human immunodeficiency virus infection. * Common cause. ¶ Life-threatening cause. Δ Potential toxins include foodborne toxin disease, poisonous plants or mushrooms, and organophosphates or carbamates. Courtesy of Gary R Fleisher, MD. Graphic 58814 Version 7.0

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Contributor Disclosures David O Matson, MD, PhD Patent Holder (maintained by Baylor College of Medicine) [Gastroenteritis (Diagnostic kit for antigen detection of calciviruses)]. Morven S Edwards, MD Grant/Research/Clinical Trial Support: Pfizer Inc. [Group B Streptococcus]. George D Ferry, MD Grant/Research/Clinical Trial Support: Eli Lilly and Company [Pediatric type 2 diabetes (Dulaglutide)]. Mary M Torchia, MD Nothing to disclose Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy

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